Publications (11)97.41 Total impact
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Article: Performance achievement award program for Get With The Guidelines--Coronary Artery Disease is associated with global and sustained improvement in cardiac care for patients hospitalized with an acute myocardial infarction.
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ABSTRACT: Adherence to evidence-based guidelines for the treatment of coronary artery disease (CAD) is suboptimal. Our goal was to determine whether the performance achievement award program for Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) was associated with global and sustained adherence to evidence-based guidelines for acute myocardial infarction. Adherence to evidence-based guidelines was assessed in 170,061 hospitalized acute myocardial infarction patients from 418 US hospitals participating in GWTG-CAD from 2000 to 2008. Hospitals that received a performance achievement award by attaining 85% adherence with 6 GWTG performance measures for at least 12 consecutive months were compared with those that had enrolled in the GWTG-CAD and had not attained this level of adherence. The outcome measures were change in adherence for 6 GWTG performance measures, 9 GWTG quality measures, a composite score, and an all-or-none measure. Generalized estimating equations were used to provide valid inference accounting for the within site correlation. Hospitals that maintained 85% adherence with GWTG performance measures for at least 12 consecutive months had a higher composite score (94.78 +/- 15.99% vs. 89.72 +/- 21.37, P < 0.0001) and an all-or-none measure (87.17% vs. 75.15%, P < 0.0001) compared with hospitals that had not yet attained this level of adherence. Hospital adherence with performance and quality measures generally improved over time. In conclusion, the performance achievement award program for GWTG-CAD was associated with global and sustained adherence to evidence-based guidelines. Our data suggest that this tool is a useful component of a quality improvement initiative and should be considered for other similar programs.Critical pathways in cardiology 09/2010; 9(3):103-12. -
Article: Rapid change in prescribing behavior in hospitals participating in get with the guidelines-stroke after release of the management of atherothrombosis with clopidogrel in high-risk patients (MATCH) clinical trial results.
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ABSTRACT: Physician prescribing patterns change slowly despite published randomized trials and consensus guidelines. We measure the effect of Management of Atherothrombosis With Clopidogrel in High-Risk Patients (MATCH) trial on discharge prescribing patterns for patients with stroke and those with transient ischemic attack in the Get With The Guidelines (GWTG)-Stroke Program. We analyzed discharge prescribing patterns of antithrombotic medications for patients admitted with ischemic stroke or transient ischemic attack at hospitals participating in GWTG-Stroke between October 2002 to January 2006. Clinical information by quarter was analyzed in relation to publication of the MATCH study. Frequency of discharge prescription of aspirin+clopidogrel post-MATCH publication was compared with the pre-MATCH period after adjusting for patient and hospital characteristics and clustering by hospital. A total of 107 872 patients at 632 sites were eligible to receive antithrombotic therapy at discharge. Use of aspirin+clopidogrel therapy declined from 22.4% to 15.4% of patients after the publication of MATCH (adjusted OR 0.62, 95% CI 0.56 to 0.70, P<0.0001). Analysis by quarter revealed a rapid and sustained decrease in use of aspirin+clopidogrel therapy for the remainder of the study period. A rapid and sustained reduction in the frequency of aspirin+clopidogrel use in ischemic stroke and transient ischemic attack was observed after publication of the MATCH trial in the absence of MATCH-specific GWTG-Stroke initiatives and preceding an American Heart Association guideline update.Stroke 09/2010; 41(9):2094-7. · 5.73 Impact Factor -
Article: Predictors of cardiac rehabilitation referral in coronary artery disease patients: findings from the American Heart Association's Get With The Guidelines Program.
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ABSTRACT: Our purpose was to determine factors independently associated with cardiac rehabilitation referral, which are currently not well described at a national level. Substantial numbers of eligible patients are not referred to cardiac rehabilitation at hospital discharge despite proven reductions in mortality and national guideline recommendations. We used data from the American Heart Association's Get With The Guidelines program, analyzing 72,817 patients discharged alive after a myocardial infarction, percutaneous coronary intervention, or coronary artery bypass graft surgery between January 2000 and September 2007 from 156 hospitals. We identified factors associated with cardiac rehabilitation referral at discharge and performed multivariable logistic regression, adjusted for clustering, to identify which factors were independently associated with cardiac rehabilitation referral. Mean age was 64.1 +/- 13.0 years, 68% were men, 79% were white, and 30% had diabetes, 66% hypertension, and 52% dyslipidemia; mean body mass index was 29.1 +/- 6.3 kg/m(2), and mean ejection fraction 49.0 +/- 13.6%. All patients were admitted for coronary artery disease (CAD), with 71% admitted for myocardial infarction. Overall, only 40,974 (56%) were referred to cardiac rehabilitation at discharge, ranging from 53% for myocardial infarction to 58% for percutaneous coronary intervention and to 74% for coronary artery bypass graft patients. Older age, non-ST-segment elevation myocardial infarction, and the presence of most comorbidities were associated with decreased odds of cardiac rehabilitation referral. Despite strong evidence for benefit, only 56% of eligible CAD patients discharged from these hospitals were referred to cardiac rehabilitation. Increased physician awareness about the benefits of cardiac rehabilitation and initiatives to overcome barriers to referral are critical to improve the quality of care of patients with CAD.Journal of the American College of Cardiology 09/2009; 54(6):515-21. · 14.16 Impact Factor -
Article: The dissociation between door-to-balloon time improvement and improvements in other acute myocardial infarction care processes and patient outcomes.
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ABSTRACT: Recent initiatives have focused on reducing door-to-balloon (DTB) times among patients with acute myocardial infarction undergoing primary percutaneous coronary intervention. However, DTB time is only one of several important AMI care processes. It is unclear whether quality efforts targeted to a single process will facilitate concomitant improvement in other quality measures and outcomes. This study examined 101 hospitals (43 678 patients with AMI) in the Get With the Guidelines program. For each hospital, DTB time improvement from 2005 to 2007 was correlated with changes in composite Centers for Medicare and Medicaid Services/Joint Commission on Accreditation of Healthcare Organizations (CMS/JCAHO) core measure performance and in-hospital mortality. Between 2005 and 2007, hospital geometric mean DTB time decreased from 101 to 87 minutes (P < .001). Mean overall hospital composite CMS/JCAHO core measure performance increased from 93.4% to 96.4% (P < .001), and mortality rates were 5.1% and 4.7% (P = .09) in the early and late periods, respectively. Improvement in hospital DTB time, however, was not significantly correlated with changes in composite quality performance (r = -0.06; P = .55) or with in-hospital mortality (r = 0.06; P = .58). After adjustment for patient mix, hospitals with the most improvement in DTB time did not have significantly greater improvements in either CMS/JCAHO measure performance or mortality. Within the Get With the Guidelines program, DTB times decreased significantly over time. However, there was minimal correlation between DTB time improvement and changes in other quality measures or mortality. These results emphasize the important need for comprehensive acute myocardial infarction quality-improvement efforts, rather than focusing on single process measures.Archives of internal medicine 09/2009; 169(15):1411-9. · 11.46 Impact Factor -
Article: Get With the Guidelines-Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack.
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ABSTRACT: Adherence to evidence-based guidelines for treatment of stroke or transient ischemic attack is suboptimal. We sought to establish whether participation in Get With the Guidelines-Stroke was associated with improvements in adherence. This prospective, nonrandomized, national quality improvement program measured adherence to guideline recommendations in 322 847 hospitalized patients discharged with a diagnosis of ischemic stroke or transient ischemic attack. A volunteer sample of 790 US academic and community hospitals participated from 2003 through 2007. The main outcome measures were change in adherence over time to 7 prespecified performance measures and a composite measure (total number of interventions provided in eligible patients divided by total number of care opportunities among eligible patients). Generalized estimating equations were used to identify factors associated with improvement. Participation in Get With the Guidelines-Stroke was associated with improvements in the 7 individual and 1 composite measures from baseline to the fifth year: intravenous thrombolytics (42.09% versus 72.84%), early antithrombotics (91.46% versus 97.04%), deep vein thrombosis prophylaxis (73.79% versus 89.54%), discharge antithrombotics (95.68% versus 98.88%), anticoagulation for atrial fibrillation (95.03% versus 98.39%), lipid treatment for low-density lipoprotein >100 mg/dL (73.63% versus 88.29%), smoking cessation (65.21% versus 93.61%), and composite (83.52% versus 93.97%) (P<0.0001 for all comparisons). Multivariate analysis showed that time in Get With the Guidelines-Stroke was associated with a 1.18-fold yearly increase in the odds of fulfilling care opportunities that was independent of secular trends. Get With the Guidelines-Stroke participation was associated with increased adherence to all stroke performance measures. Markedly improved stroke care was seen in all hospitals regardless of size, geography, and teaching status.Circulation 12/2008; 119(1):107-15. · 14.74 Impact Factor -
Article: Quality of care and outcomes among patients with heart failure and chronic kidney disease: A Get With the Guidelines -- Heart Failure Program study.
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ABSTRACT: Both heart failure (HF) and chronic kidney disease (CKD) are highly prevalent conditions that often coexist; however, the quality of care received by hospitalized patients with both is not known. The Get With the Guidelines - HF registry and performance improvement program prospectively collects data on patients hospitalized with HF. Performance measures to improve treatment of patients with HF and inhospital mortality were examined by kidney function based on glomerular filtration rate (GFR) categorized as normal (GFR > or = 90), mild (60 < or = GFR < 90), moderate (30 < or = GFR < 60), severe (15 < or = GFR < 30), and kidney failure (GFR < 15 or dialysis). Nearly two thirds of hospitalized patients with HF (15,560 patients from 137 hospitals) also had CKD: moderate CKD (43.9%), severe CKD (14.2%), and kidney failure (6.6%). Inpatient mortality was higher for patients with more severe renal dysfunction. Those with kidney failure were significantly less likely to receive nearly all guidelines-based therapies. In contrast, those with moderate or severe CKD often received similar care when compared with those with normal kidney function, except for lower use of angiotensin-converting enzyme inhibitors or receptor blockers (odds ratio 0.19 [0.13-0.28] and 0.47 [0.36-0.62], respectively) and lower proportions with blood pressure control (odds ratio 0.70 [0.58-0.85] and 0.52 [0.42-0.63], respectively). In a large contemporary cohort of patients hospitalized with HF, we found that renal dysfunction was a highly prevalent comorbidity. Despite higher mortality rates, patients with increased severity of renal dysfunction were less likely to receive important guideline-recommended therapies. Further efforts are needed to improve the care of patients with HF and CKD.American heart journal 10/2008; 156(4):674-81. · 4.65 Impact Factor -
Article: Multidisciplinary rounds (MDR): an implementation system for sustained improvement in the American Heart Association's Get With The Guidelines program.
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ABSTRACT: Hospitals throughout the United States face the challenge of developing implementation systems able to sustain improved clinical care over years. The American Heart Association's Get With The Guidelines (GWTGs) program helps hospitals address this challenge with a comprehensive approach to quality improvement for patients with CAD, heart failure and stroke. The Department of Medicine at Berkshire Medical Center, a 300-bed community teaching hospital, developed a clinical care improvement implementation system called multidisciplinary rounds (MDR). We report our performance in GWTGs using MDR. MDR is a patient-focused communication system integrating care delivered by multiple providers using concurrent feedback, redundancy, and rapid cycle improvement. Providers from multiple disciplines meet for 1 hour 3 times per week to coordinate care and assure adherence to evidence-based guidelines for all non-ICU medical patients. Following brief focused presentations, participants view our electronic medical record (EMR) projected on screens, which includes orders, diagnoses, laboratory, medications, cardiology reports, consultations, nursing documentation, smoking and immunization status, and other information. The leaders emphasize the importance of evidence-based order sets in our computerized provider order entry system (CPOE), checklists, and tools. Specific suggestions for interventions and documentation based upon AHA/ACC guidelines are provided. MDR has rapidly improved adherence to evidence-based measures in all GWTGs programs. In addition, MDR has been associated with sustained improvement in all modules. Berkshire Medical Center has received more performance achievement awards than any other hospital in the United States. These awards include 6 consecutive awards in GWTGs CAD, 3 in stroke, and 2 in heart failure. Cardiovascular process improvements have been associated with a reduction in inpatient AMI mortality from 8.75% to 5.20% (with an expected severity-adjusted mortality of 10.18%). Berkshire Medical Center provides about 80% of the acute care in Berkshire County and thus influences the outcomes of a large proportion of our community's patients. Between 1999 and 2004, Berkshire County had a 26.3% decrease in major CVD deaths compared with a Massachusetts decrease of 17.3% and a US decrease of 17.8%. We have seen a 44.4% decrease in AMI mortality, a 34.5% decrease in stroke mortality, and a 33.9% decrease in heart failure mortality. We have assisted multiple organizations in implementing GWTG and MDR. MDR at Berkshire Medical Center is a clinical quality-improvement implementation system that has driven sustained high-level performance in the American Heart Association's GWTGs. MDR has changed our culture, improved coordination of care, been flexible, and facilitated rapid and sustained process improvement. Improvement in evidence-based cardiovascular processes for CAD, stroke and heart failure have been associated with improved in hospital AMI mortality and decreased overall community cardiovascular, AMI, stroke and heart failure mortality. MDR can be used by multiple organizations to drive care improvement.Critical pathways in cardiology 10/2007; 6(3):106-16. -
Article: Development of systems of care for ST-elevation myocardial infarction patients: the non-percutaneous coronary intervention-capable (ST-elevation myocardial infarction referral) hospital perspective.
Circulation 08/2007; 116(2):e49-54. · 14.74 Impact Factor -
Article: Recommendation to develop strategies to increase the number of ST-segment-elevation myocardial infarction patients with timely access to primary percutaneous coronary intervention.
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ABSTRACT: Although evidence suggests that primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy in the majority of patients with ST-segment-elevation myocardial infarction (STEMI), only a minority of patients with STEMI are treated with primary PCI, and of those, only a minority receive the treatment within the recommended 90 minutes after entry into the medical system. Market research conducted by the American Heart Association revealed that those involved in the care of patients with STEMI recognize the multiple barriers that prevent the prompt delivery of primary PCI and agree that it is necessary to develop systems or centers of care that will allow STEMI patients to benefit from primary PCI. The American Heart Association will convene a group of stakeholders (representing the interests of patients, physicians, emergency medical systems, community hospitals, tertiary hospitals, and payers) and quality-of-care and outcomes experts to identify the gaps between the existing and ideal delivery of care for STEMI patients, as well as the requisite policy implications. Working within a framework of guiding principles, the group will recommend strategies to increase the number of STEMI patients with timely access to primary PCI.Circulation 06/2006; 113(17):2152-63. · 14.74 Impact Factor -
Article: Improving quality of care through disease management: principles and recommendations from the American Heart Association's Expert Panel on Disease Management.
Circulation 07/2004; 109(21):2651-4. · 14.74 Impact Factor -
Article: A randomized trial of an acid-peptic disease management program in a managed care environment.
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ABSTRACT: To study the effectiveness of a disease management program for patients with acid-related disorders. A cluster-randomized clinical trial of 406 patients comparing a disease management program with "usual practice." Enrolled patients included those presenting with new dyspepsia and chronic users of antisecretory drugs in 8 geographically separate physician offices associated with the Orlando Health Care Group. There were 35 providers in the intervention group and 48 in the control group. The disease management program included evidence-based practice guidelines implemented by using physician champions, academic detailing, and multidisciplinary teams. Processes of care, patient symptoms, quality of life, costs, and work days lost were measured 6 months after patient enrollment. Compared with usual practice, disease management was associated with improvements in Helicobacter pylori testing (61% vs 9%; P = .001), use of recommended H pylori treatment regimens (96% vs 10%; P = .001), and discontinuation rates of proton pump therapy after treatment (70% vs 36%; P = .04). There were few differences in patient quality of life or symptoms between the 2 study groups. Disease management resulted in fewer days of antisecretory therapy (71.7 vs 88.1 days; P = .02) but no difference in total costs. This disease management program for patients with acid-related disorders led to improved processes of care. The effectiveness of such a program in other settings requires further study.The American journal of managed care 07/2003; 9(6):425-33. · 2.46 Impact Factor
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2010
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University of Houston
- Department of Clinical Sciences & Administration
Houston, TX, USA
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